Reconstruction after mastectomy.

Ellen Parker * has always taken pride in her breasts. So after her breast cancer diagnosis in 1991, when she learned she'd need a mastectomy, she was pleased to hear she could have an immediate reconstruction.

And, indeed, she woke up in the recovery room with a tissue expander in place of the missing breast, the first step in the two-step reconstruction procedure using a breast implant.

On the advice of her doctor, Ms. Parker, now 58, who lives in Arlington, VA, opted for a silicone implant.

But instead of the cosmetic results she had hoped for, the implant sat stiff and high on her chest, looking little like her other breast. By the time it ruptured 14 years later (a common occurrence with older saline and silicone implants) (11), she was relieved. "I was never happy with it," recalls Ms. Parker.

Soon after her implant, the U.S. Food and Drug Administration (FDA) limited silicone-gel implants to controlled clinical studies involving cases of mastectomy, replacement of ruptured silicone implants or correction of congenital deformities. Earlier this year two manufacturers of silicone implants received "approvable with conditions letters" from the FDA for their products. Once the conditions are met, silicone implants likely will be available again in the U.S. Meanwhile, most reconstructions are done with saline implants.

Ms. Parker's experience isn't entirely unusual--studies find that about one in three women receiving an implant for reconstruction, regardless of the type of implant used, required another operation within five years. (12), (13)

However, today's implant shells are nearly twice as thick as those of the old silicone-gel implant.

Additionally, manufacturers have added a barrier between the inner and outer layers of the implant to prevent silicone from leaking from the implant if it ruptures. Also, the outside of the implant shell is usually textured, which studies find results in fewer incidences of contracture, a condition in which fibrous tissue grows around the implant. (14)

Nonetheless, Ms. Parker didn't want another implant. Instead, in September 2005 she underwent a new type of breast reconstruction that uses fat and tissue--but not muscle--from her abdomen to shape a realistic-looking and feeling breast. One month later, still recovering from the surgery, she was ecstatic.

"I'm so excited I can hardly stand it," she says. The heft, the droop, everything about her new breast matches the untouched breast, she says, and under clothes you can't tell the two apart.

That's the goal, says her doctor, Maurice Nahabedian, MD, associate professor of plastic surgery at Georgetown University in Washington, DC.

He is one of only a handful of specialists in the U.S. using this new reconstruction technique, called the DIEP (deep inferior epigastric perforator) flap. The procedure is a variation of the most commonly performed breast reconstruction surgery method, the TRAM flap, in which muscle, tissue and fat are removed from the transverse rectus abdominis muscle (TRAM) in the lower abdomen.

In both operations, the lower abdomen is the principle source of tissue. During a TRAM flap, the surgeon removes the tissue, fat and the muscle to preserve the major blood supply that runs through the muscle for use in the new breast. With the DIEP flap the surgeon doesn't remove the muscle, so there's very little change in abdominal strength and a faster recovery time, says Dr. Nahabedian.

In the traditional TRAM flap, women lose up to 40 percent of abdominal strength for a single breast reconstruction; up to 70 percent if both breasts are done. With the DIEP flap, they can do everything they're used to doing, even sit-ups, Dr. Nahabedian explains.

The downside is the complexity of the procedures. Surgeons carefully tease blood vessels away from the muscle, preserving the nerves. During reconstruction, they painstakingly connect those tiny blood vessels via microscopic surgery to vessels in the chest, providing the new breast with its own critical blood supply.

Because the surgery is so complex, he says, it's critical to find a specialist in the procedure. If it isn't performed properly, the breast tissue could die and become infected, putting a woman's overall health at risk.

As for Ms. Parker, she's excited about being able to work out at the gym without stuffing a towel into her sports bra, and being able to wear the bright, sexy tops she's been saving for her new breast. "It's just a miracle," she says.

* Not her real name

References

(11) Bondurant S, Ernster V, Herdman R. Safety of Silicone Breast Implants, Report of the committee on the Safety of Silicone Breast Implants (IOM). Washington, D.C.: National Academy Press. 1999.

(12) FDA Breast Implant Consumer Handbook, US Food and Drug Administration. 2004.

(13) Gabriel SE, Woods JE, O'Fallon WM, et al. Complications leading to surgery after breast implantation. N Engl J Med. 1997 Mar 6;336(10):677-82.

(14) Smith RA, Saslow D, Sawyer KA, et al. American Cancer Society Guidelines for Breast Cancer Screening: Update 2003. CA Cancer J Clin. 2003;53:141-169.